Context.— Previous studies have found that fewer minority medical school faculty
hold senior professorial ranks than do majority faculty and may not be promoted
as rapidly.

Objective.— To determine whether minority faculty were as likely as majority faculty
to have attained senior rank (associate professor or full professor) after
adjusting for other factors that typically influence promotion.

Design.— A self-administered mailed survey of US medical school faculty using
the Association of American Medical Colleges database. The sample was stratified
by department, graduation cohort, and sex.

Participants.— A stratified random sample of 3013 full-time faculty at 24 representative
US medical schools. All underrepresented minority faculty at these schools
were sampled.

Main Outcome Measure.— Attainment of senior academic rank (associate professor or full professor).

Conclusions.— Minority faculty were less likely than white faculty to hold senior
academic rank. This finding was not explained by potential confounders such
as years as a faculty member or measures of academic productivity.

RECENT EFFORTS to improve the representation of minority faculty in
academic medicine have focused on increasing the number of minority physicians
who pursue academic careers.1,2
However, the number of minority students entering medical schools has plateaued,
despite efforts to achieve racial and ethnic diversity in US medical schools,
such as the Association of American Medical Colleges (AAMC) Project 3000 by
2000.1- 3 Minority
medical students and resident physicians in academic medical centers have
few role models.4 Data derived from the AAMC
Faculty Roster System show that only 3.9% of all faculty identify themselves
as black, Native American, Mexican American, or Puerto Rican.5
The AAMC classifies these groups as "underrepresented" in medicine because
the proportion of physicians in these groups is less than in the general population.6 Other minority groups, such as Asian Americans, are
not classified as underrepresented.

In 1989, Petersdorf et al6 reported that
underrepresented minority faculty were far less likely to have achieved the
rank of associate or full professor than majority faculty. This difference
may have been partly due to minority faculty being, on average, younger. They
also noted that minorities were not promoted to associate professor rank as
quickly as majority faculty.

Literature on promotion and tenure includes opinion pieces regarding
the merit of tenure,7- 9
articles that explore the process of promotion for medical school faculty,10,11 and reports on the promotion of women
faculty in academic medicine.12- 14
The AAMC has reported on the promotion experience of minority medical school
faculty6 but, due to limitations of the AAMC
database, was not able to control for other important factors that affect
promotion, such as academic productivity. In the current study, we examined
whether minority faculty were as likely as majority faculty to have attained
senior rank (associate or full professor) after controlling for such factors.

METHODS

Sampling

In 1995 we used a 2-stage sampling plan to draw a stratified random
sample of full-time salaried faculty of US medical schools. Of the 126 medical
schools in the AAMC's 1994 lists, we excluded the 6 schools outside the contiguous
United States because the AAMC considers them to be significantly different
from mainland schools. Also, to make it possible to select about 150 faculty
(including similar numbers of women and men and adequate numbers of minorities)
from each sampled school, we excluded 14 small schools (ie, having fewer than
200 faculty members). Retained schools had faculties of at least 200, containing
at least 50 women and 10 minority faculty. Altogether, only 5% of medical
school faculty are affiliated with the small schools. We randomly selected
24 schools from the remaining 106 eligible schools. Numbers of faculty at
the sampled schools were similar to those in this population of eligible schools.
This sample also achieved regional diversity across the 4 AAMC regions and
a balance of public and private institutions.

In the second stage we created a sampling frame from the full-time salaried
faculty listed by the AAMC Faculty Roster System at the 24 selected medical
schools exclusive of 720 faculty (4%) in unique departments (such as veterinary
medicine) that did not exist at other medical schools. We identified our survey
sample from the 16714 faculty members in the sampling frame, first through
a 2 × 24 × 4 × 3 factorial design that sought 6 randomly
selected male and female faculty members from each sampled school in each
of 4 academic department groupings (generalists vs surgical specialists vs
medical and other specialists vs basic scientists) in each graduation cohort
(those who completed their first doctorate before 1970 vs between 1970 and
1980 vs after 1980). The oldest graduation cohort cells were filled first
and back-filled, if necessary, with younger faculty. We expanded the sample
to include all underrepresented minority, generalist, and senior women faculty
at these 24 schools. The total sample included 4051 faculty members.

Data Collection

The questionnaires were mailed to faculty at their professional addresses;
1038 were ineligible because they had left their institution, were not full-time
faculty, or had died. Nonrespondents among the remaining 3013 subjects were
mailed a reminder postcard and, if necessary, had a follow-up telephone call
and were sent a second questionnaire. We assigned a final project disposition
to every participant through contact records, which contained dates of the
mailings and telephone reminder calls and the final disposition.

The survey instrument examined various aspects of academic life among
medical school faculty. The survey was pretested by 45 medical school faculty
at 3 institutions to ensure that the respondents understood the meaning of
the questions and could answer them appropriately. Many questions were taken
from previously published studies.15,16
Thirty questions used in the survey were developed by Linda Fried, MD, MPH,
and Clair Francomano, MD, Johns Hopkins Medical Institutions, Baltimore, Md,
and were used in the original form or modified for use in our instrument with
permission. The self-administered survey included 177 questions about faculty
demographics; professional goals and work situation; current academic environment
and rank; mentoring relationships; experiences with bias, discrimination,
and harassment; academic productivity; family responsibilities; faculty compensation;
and career satisfaction. Items examining attitudes used Likert scales.17 Other items required circling 1 item within a group
of items or recording a number or percentage. This study was approved by the
Boston University School of Medicine Institutional Review Board.

Statistical Analysis

We coded departments as follows: generalists (general internal medicine,
general pediatrics, family medicine, and geriatrics); surgical specialists
(general surgery and its subspecialties); medical and other specialists (internal
medicine subspecialties, pediatric subspecialties, neurology, physical medicine,
radiology, emergency medicine, anesthesia, and psychiatry); and basic scientists.
For analysis, we created 4 racial and ethnic groups from the self-reported
ethnic and racial categories in the questionnaire: white, not of Hispanic
origin; black, not of Hispanic origin; Asian; and Hispanic.

We used descriptive statistics to characterize the majority and minority
survey respondents because the distribution of characteristics of surveyed
white faculty is a function of our factorial sampling design, whereas the
proportion of the other ethnic groups reflects the results of full census
sampling in the 24 study schools.

We used conditional logistic regression18
to determine the likelihood of minority faculty holding senior rank (associate
or full professor) compared with white faculty within the strata defined by
departments within medical schools. We adjusted for the following potential
confounders: the number of years as a medical school faculty member (continuous)
and years as medical school faculty, squared, to capture the declining influence
of additional years on the likelihood of senior rank; the number of first-authored,
peer-reviewed publications (<5 vs 5-9 vs ≥10); current research grant
support (yes or no); sex; percentage of clinical time; and tenure status (tenured
or tenure track vs nontenured).

We also classified respondents as white, underrepresented minority (black,
Puerto Rican, and Mexican American), and nonunderrepresented minority (Asian
and other Hispanic, such as Cuban)6 and replicated
the previous analysis for underrepresented and nonunderrepresented minority
groups relative to white faculty, adjusting for the same covariates. We tested
for the presence of interaction terms for ethnicity by sex, tenure status,
school, region of school, and private vs public school. Analyses were performed
using SAS statistical software, Version 6.11 (SAS Institute Inc, Cary, NC).

RESULTS

Faculty Respondent Characteristics

Of 3013 eligible faculty members who received the survey, 1807 returned
it for a response rate of 60%. Due to confidentiality concerns of the AAMC,
we are not able to calculate response rates within racial and ethnic subgroups.
Eighty-one percent identified themselves as white, not of Hispanic origin;
8.5% as black, not of Hispanic origin; 7.5% as Asian; and 3.0% as Hispanic.
There were fewer women among black and Hispanic faculty in our sample (Table 1). Fewer black faculty reported
having board certification and postgraduate degrees. Black faculty were less
likely to be in a basic science department than other faculty. At the time
of the survey, 980 respondents (54%) reported senior faculty positions (associate
professor or full professor), including 47 (30.5%) of 154 black faculty, 59
(43.4%) of 136 Asian faculty, 22 (40.8%) of 54 Hispanic faculty, and 852 (58.3%)
of 1463 white faculty. More white faculty than others were tenured or on a
tenure track, and they were also more likely than other faculty to have attained
senior rank regardless of their tenure status.

Language Skills and Attitudes

Many of the minority faculty were not US born, particularly Asians,
for whom 80% were born outside the United States (Table 2). For Asian and Hispanic faculty, being foreign-born was
associated with a primary language other than English. All groups rated their
aspirations to become full professors similarly. Only 20% of the faculty respondents
felt their rank was lower than other faculty with equivalent accomplishment
and experience at their institution. The reasons these individuals attributed
for their lower rank were similar across groups, except that more black and
Asian faculty reported ethnic or racial bias and more Hispanic and Asian faculty
reported inadequate negotiation skills.

Academic Activities and Productivity

All groups reported similar hours worked during a typical workweek (Table 3). Black faculty spent more time
in clinical activities and less time in research relative to other faculty.
More black and Hispanic faculty felt pressure to serve on committees due to
their race or ethnicity, but they did not spend more time in hours per month
on committee-related activities than the other groups. More white faculty
held research grants during the previous 2 years than Hispanic faculty, but
there were no differences in the types of grant funding (governmental vs private
vs industry) or the median number of research grants held between the groups.
White faculty also had more first-authored and total peer-reviewed publications
than the other groups.

Multivariate Analysis

After adjustment for measures of academic productivity (publications
and grants) and other factors that affect attaining senior rank, minority
faculty were less likely to have been promoted to associate or full professor
compared with white faculty (Table 4).
Compared with white faculty, the adjusted odds ratios (ORs) of having senior
rank for black faculty were 0.33 (95% confidence interval [CI], 0.17-0.63);
for Hispanic faculty, 0.36 (95% CI, 0.12-1.08); and for Asian faculty, 0.58
(95% CI, 0.30-1.12). These results were unchanged whether first-authored or
total publications were used, either continuously or categorically defined,
or whether years as a faculty member was coded as a continuous or categorical
variable. Adjusting for the same variables, we found that underrepresented
minority faculty were significantly less likely to have been promoted to senior
academic rank compared with white faculty. The adjusted OR for having attained
senior rank for these underrepresented minority faculty was 0.29 (95% CI,
0.16-0.54), and for nonunderrepresented minority faculty, the OR was 0.64
(95% CI, 0.34-1.20). In a similar multivariate model with rank of full professor
as the outcome variable (data not shown), the estimated effect for each racial
or ethnic group continued to show a lower likelihood of holding senior rank
compared with white faculty. These effects were not as large as they were
in the main analysis and the statistically significant effect for black faculty
was less (P=.05 vs P=.007,
primary analysis). The influence of each racial or ethnic group on the likelihood
of attaining senior rank was similar by sex, tenure status, location of the
medical school, or public or private status of the medical school.

COMMENT

Our study found large racial and ethnic disparities in the attainment
of senior rank among US medical school faculty. Black faculty were significantly
less likely than white faculty to hold senior rank. Moreover, this disparity
persisted after adjustment for potential confounders. Hispanic and Asian faculty
were also much less likely than white faculty to have attained senior rank,
although these differences were smaller and not statistically significant
(P=.07 and P=.10, respectively).
Underrepresented minority faculty, who were predominantly black and Mexican
American in our sample, were less than a third as likely than majority faculty
to have attained the rank of associate or full professor.

Difficulties with the advancement of underrepresented minority faculty
have been noted by Petersdorf et al.6 Their
study also relied on the AAMC database but did not have the ability to adjust
for potentially confounding factors. To our knowledge, our study is the first
to comprehensively address the issue of promotion among minority faculty in
all medical school departments in a representative, national sample of US
medical schools. The underrepresentation of minority faculty at senior ranks
is not explained by their younger age. After controlling for the number of
years of medical school faculty appointment, these faculty remained substantially
less likely to have attained senior rank than white faculty.

Underrepresented minority faculty have been reported to have a greater
debt burden than other faculty,1,6,19
which may partly explain the greater clinical activity and lower levels of
research time among black and Hispanic faculty in our study. Economic factors
may make it more difficult for these faculty to participate in research activities
and publish in peer-reviewed journals. In addition, more black and Hispanic
faculty may be on clinical tracks, in which promotion to senior levels is
slower. However, after controlling for the percentage of time spent in clinical
work, black faculty were still less likely to hold senior rank.

All of the groups rated their aspiration to be a full professor and
the likelihood of becoming a full professor similarly, so that the observed
shortfall in attaining senior rank cannot be attributed to lesser ambition.
Negotiation skills have been recognized as important for career development
and advancement.20 Yet, we found little overall
differences in the self-reported assessments of negotiation skills by racial
and ethnic group. Nevertheless, among the one fifth of faculty who thought
they were at a lower rank relative to similarly prepared and accomplished
peers, more Hispanic and Asian faculty attributed their lower rank to inadequate
negotiation skills. This may be due to differences in communication styles
and cultural differences, since higher proportions of faculty from these 2
groups were born outside the United States.

Reasons to explain the underrepresentation of minority faculty in senior
ranks are unclear. Discrimination, which may be less obvious than in the past,
is a possibility.21 The stereotypes of minority
groups that permeate society at large may carry over into academic medicine.
Cultural differences may contribute to some minority faculty being excluded
from certain opportunities or informal information sharing that could be helpful
to their career development. Cultural differences and historical factors also
may make some minority faculty reluctant to network at the divisional or departmental
level, thus reducing their chance to forge personal and professional relationships
with majority colleagues.

A potential limitation of our study is that the faculty productivity
measures were self-reported. However, we see no reason to suspect systematic
discrepancies between actual and reported numbers of publication by race or
ethnicity. We also could not evaluate the quality of the publications or other
academic activities of our respondents, but there is no evidence that minority
faculty publish articles of lesser quality. Our measure of academic performance
was research based and, thus, did not capture the achievements of faculty
in other areas, including teaching and administration. Nevertheless, on the
basis of time commitment to these latter 2 activities, white faculty were
similar to the largest minority group, black faculty. Another potential concern
about our study is response bias. Because of confidentiality concerns of the
AAMC, we cannot compare the characteristics of respondents and nonrespondents
by race and ethnicity. However, the proportion of minority faculty with senior
rank in our sample (30% for black faculty, 43% for Asian faculty, and 41%
for Hispanic faculty) is similar to that recorded in the AAMC Faculty Roster
(28% for black faculty, 38% for Asian faculty, and 39% for Hispanic faculty).5 Thus, black faculty at lower ranks did not disproportionately
respond to our questionnaire. We found that 58% of white faculty had senior
rank in contrast with the 52% recorded by the AAMC, but this difference most
likely is due to our oversampling of senior faculty and should not affect
the findings of our multivariate analysis. We could not adjust for all factors
that affect attaining senior rank that may differ among racial and ethnic
groups, such as the different tenure tracks that are in place at various medical
schools. Also, our results cannot be generalized to historically black medical
schools because they were not included in our study. Finally, given that this
was a cross-sectional survey and not an inception cohort, we have no data
from individuals who have left academic medicine. It is likely that data from
those who remain at academic centers underestimate the negative effect of
being in a minority group on the chance of attaining senior rank.22

Our findings suggest a number of possible interventions. First, the
research careers of minority faculty, particularly black and Hispanic faculty,
should be encouraged and supported financially because more research activities
should increase the likelihood of promotion.23
Second, the promotion criteria at each institution should be evaluated to
ensure that teaching and administrative activities are sufficiently rewarded.
This would include greater value placed on scholarly activities other than
publication, such as excellence in teaching, the performance of administrative
responsibilities, and service to the community served by the medical school.
Third, external reviewers blinded to the race and ethnicity of the faculty
member should evaluate the candidate's curriculum vitae for promotion to limit
the potential for ethnic and racial bias. Fourth, medical schools should disseminate
their promotion and tenure procedures, offer formal career counseling and
faculty development programs, and establish formal monitoring processes for
their faculty as recommended by the American College of Physicians.19 In addition, qualitative studies may have a role
in identifying the factors minority faculty perceive as barriers to their
advancement and in suggesting effective interventions. More minority faculty
in senior positions would help provide role models and mentors to minority
junior faculty, resident physicians, and medical students.

Armed with the results of our study and the reality of an increasingly
diverse US population, medical school deans and department heads need to foster
and provide greater support for the careers of minority faculty to ensure
their equitable representation at all levels in academic medicine.